Evidence-Based Management of Pulmonary Embolism in the Emergency Department

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Delivery Method:	Online
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Publication Date: August 2023 (Volume 25, Number 8)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 08/01/2026.

Authors

Peer Reviewers

Abstract

Patients with pulmonary emboli present both diagnostic and therapeutic challenges to the emergency clinician, because initial symptoms can be variable and overlap with other medical conditions. This issue reviews treatment options for patients with pulmonary emboli based on risk stratification scores of low, intermediate-low, intermediate-high, and high risk classifications. The evidence on laboratory testing and imaging is presented, as well as treatment strategies that include anticoagulation, thrombolytics, and mechanical or surgical thrombectomy. Management decisions regarding pregnancy and COVID-19 are discussed, as well as considerations for outpatient treatment of low-risk patients.

Case Presentations

An obese 55-year-old man reports exertional dyspnea that began 2 days prior…

• The man says he is generally active, despite being obese, and says that he walks extensively for his job.
• His ECG is normal sinus rhythm at 95 beats/min and his resting pulse oximetry is at 94%. There are no other abnormalities. Chest x-ray, natriuretic peptide, and high-sensitivity troponin are normal.
• All of his symptoms can be explained by his weight, but you wonder whether you should start down a diagnostic pulmonary embolism algorithm...

A 65-year-old woman presents with a complaint of shortness of breath she developed that morning…

• She says she recently recovered from COVID-19 disease and was doing well prior.
• On examination, her lungs have a few residual ronchi from her illness, but are otherwise clear. Vital signs are normal, and her pulse oximetry is 97% on room air. As part of her workup, a D-dimer is ordered and returns incalculably high. She has a well-documented IV contrast allergy. A pulmonary perfusion scan was ordered, which shows a clear perfusion defect consistent with a pulmonary embolism.
• You consider whether this patient is a candidate for outpatient treatment and which medications to use...

A 60-year-old woman presents in extremis via basic EMS…

• She was recently released from the hospital following a 1-week hospitalization for COVID-19 disease, during which she was placed on low-molecular-weight heparin (LMWH). She stopped the LMWH 4 days prior. She said she developed severe shortness of breath about 1 hour ago when she stood up from a recliner she had been resting in.
• On arrival to the ED, she was cyanotic, tachypneic, tachycardic, and verbalizing “I can’t breathe” repeatedly. Initial pulse oximetry was 70%, with a sinus tachycardia of 130 beats/min and a blood pressure of 84/40 mm Hg.
• Does this patient require endotracheal intubation, and should thrombolytics be started immediately?

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